PFD report

Mr Joel Kenneth Ineson · Prevention of Future Deaths report

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Issued 10 Apr 2025•Sunderland

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
8

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised8

  1. Lack of emergency plans for organised open water swimming events
    Part of recurring concern: Inadequate regulatory oversight of organised public eventsPart of recurring concern: Unreliable emergency arrangements for organised public eventsPart of recurring concern: Unreliable safety arrangements for organised water-sports events
  2. Failure to maintain an accurate record of who is in the water and how many people are in the water
  3. Unclear responsibility for safety measures at organised open water swimming events
    Part of recurring concern: Unclear allocation of safety responsibilities at organised public eventsPart of recurring concern: Unreliable safety arrangements for organised water-sports events
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Continue supporting and liaising with local-authority regulatory partners on enforcement of work-related health and safety legislation.

    Stated by Health and Safety ExecutiveStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Enforcement responsibility lies with HSE or the relevant local authority, with local authorities predominantly enforcing work-related health and safety legislation in this area.

    Stated by Health and Safety ExecutiveRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of emergency plans for organised open water swimming events

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Inadequate regulatory oversight of organised public events; Unreliable emergency arrangements for organised public events; Unreliable safety arrangements for organised water-sports events.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to maintain an accurate record of who is in the water and how many people are in the water

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unclear responsibility for safety measures at organised open water swimming events

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Unclear allocation of safety responsibilities at organised public events; Unreliable safety arrangements for organised water-sports events.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of specific health and safety guidance and compliance requirements for event risk assessments

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Inadequate regulatory oversight of organised public events; Unreliable guidance and communication for safety risk assessments; Unreliable safety arrangements for organised water-sports events.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of regulatory licensing and oversight for organised open water swimming events

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Inadequate regulatory oversight of organised public events; Unreliable safety arrangements for organised water-sports events.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of training requirements for open water swimming event organisers

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Inadequate regulatory oversight of organised public events; Unreliable safety arrangements for organised water-sports events.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of knowledge of participant competency and capability

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Inadequate individual risk assessment for activities.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to provide specific pre-session safety briefings

Wider context from the report

“Open Water Swimming is becoming a popular way of keeping fit. Mr Ineson was a keen participant in organised open water swimming events with safety at the forefront of his mind with a reasonable expectation that appropriate safety measures would be in place for an organised event. He attended such an event on 31st May 2023 which was well attended, and the organisers indicated that this had been a popular event when it had taken place. This event, like many similar events, charged participants a small fee for the session. The matters of concern were not found to be causative of Mr Ineson’s death but were such that there is a risk that future deaths could occur unless action is taken. I was concerned that the evidence highlighted uncertainty and confusion with regard to responsibility for aspects of safety measures leading to some participants not receiving a specific safety briefing, a lack of knowledge of the competency/capability of each and every participant and no understanding as to who was in the water and how many people were in the water at any one time. It became clear in evidence that the activity does not require a licence from the Adventure Activities Licensing Authority and can be undertaken and/or organised by anyone without regulation. Some organisations provide guidance on safety when organising such events, but there is no established UK body that provides regulation for this activity. It was confirmed there is no specific health and safety guidance, nor is there a regulatory compliance requirement regarding pre-session safety briefing, risk assessments, signing in and out of the water systems, emergency plans and/or training for organisers. The evidence indicated there is no oversight of these events which, by definition, take place in outdoor locations that may pose a risk. I shall be glad to be told of any learning arising from this death and timescales and results of your review. ”

Is this part of a recurring concern?

Yes — Unreliable pre-activity safety information for organised water activities; Unreliable safety arrangements for organised water-sports events.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue supporting and liaising with local-authority regulatory partners on enforcement of work-related health and safety legislation.

Verbatim wording from the response

“HSE will continue to support and liaise with our regulatory partners in local authorities who are predominantly responsible for the enforcement of work related health and safety legislation in this area.”

Source location

Response from Health and Safety Executive
Page 2 · response
Published 17 April 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Enforcement responsibility lies with HSE or the relevant local authority, with local authorities predominantly enforcing work-related health and safety legislation in this area.

Verbatim wording from the response

“Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.”

Source location

Response from Health and Safety Executive
Page 1 · response
Published 17 April 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing regulations and guidance provide a suitable basis for safe public open water swimming, so HSE will not publish specific guidance.

Verbatim wording from the response

“Organisers of open water swimming events for the public are required to comply with the Health and Safety at Work etc. Act 1974 (HSWA) and the Management of Health and Safety at Work Regulations 1999 (MHSWR). As set out in the Health and Safety (Enforcing Authority) Regulations 1998, this legislation is enforced by either HSE or the local authority, depending upon where the event is taking place and who is organising it. HSWA and MHSWR provide a framework for securing health, safety and welfare by requiring businesses organising such events to identify risks to their workers and customers/competitors from their activities and to take action by putting in place suitable measures to manage those risks.”

Source location

Response from Health and Safety Executive
Page 1 · response
Published 17 April 2025

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

An AALA licence is not relevant because the licensing scheme concerns specified tuition for children, not adult swimming events.

Verbatim wording from the response

“The Adventure Activities Licensing Regulations 2004 have a very specific purpose and were never intended to apply to all adventure activities or adult adventure activities. The Adventure Activities Licensing Authority (AALA) licence is aimed at those who provide tuition in specified adventure activities to children, and therefore it was not relevant to a swimming event for adults.”

Source location

Response from Health and Safety Executive
Page 2 · response
Published 17 April 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Request that open-water-swimming safety matters be raised at the national Local Authority Health and Safety Practitioner Forum.

    Stated by Health and Safety ExecutiveStated completedThe respondent said that this action was complete when they made their response on 17 April 2025.
  2. 2

    Write to Swim England to explore increasing awareness of Beyond Swim and related guidance and support, and request a report back.

    Stated by Department for Digital, Culture, Media and SportStated plannedThe respondent said that this action was planned when they made their response on 17 April 2025.
  3. 3

    Continue working with sports bodies and encouraging sports and event organisers to prioritise participant safety.

    Stated by Department for Digital, Culture, Media and SportStated in progressThe respondent said that this action was in progress when they made their response on 17 April 2025.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Request that open-water-swimming safety matters be raised at the national Local Authority Health and Safety Practitioner Forum.

Verbatim wording from the response

“To increase awareness among local authority enforcement officers I have asked that this matter is raised at the national Local Authority Health and Safety Practitioner Forum (https://www.hse.gov.uk/lau/national-committees.htm).”

Source location

Response from Health and Safety Executive
Page 2 · response
Published 17 April 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Write to Swim England to explore increasing awareness of Beyond Swim and related guidance and support, and request a report back.

Verbatim wording from the response

“These are positive steps but, as your report highlights, it is important to ensure good awareness of safety standards in open water swimming. I will therefore write to Swim England to explore how awareness of “Beyond Swim” and associated guidance and support can be increased, and ask them to report back to me. More generally, I will continue to work with sports bodies to ensure that safety is prioritised.”

Source location

Response from Department for Culture Media and Sport
Page 2 · response
Published 17 April 2025

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue working with sports bodies and encouraging sports and event organisers to prioritise participant safety.

Verbatim wording from the response

“Please allow me to pass on my sincere condolences to the family and friends of Mr Ineson for their loss. This was a tragic event, and I share your desire to ensure that all possible lessons can be learned. The safety and wellbeing of everyone taking part in sporting events is of paramount importance, and I will continue to push sports and event organisers to do everything they can to prioritise this.”

Source location

Response from Department for Culture Media and Sport
Page 1 · response
Published 17 April 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026